IVIG - BMC HealthNet Plan

y a rheumatologist or in consultation with a rheumatologist. IVIG has been used in
children with polyarticular or systemic JRA that was unresponsive to standard
therapy (corticosteroids, methotrexate, abatacept [Orencia ® ], adalimumab [Humira ® ],
etanercept [Enbrel ® ]). 27
25. Lambert-Eaton myasthenic syndrome (treatment). Approve for 12 months in
patients who meet all of the following criteria (A, B, and C).
A. IVIG is prescribed by or in consultation with a neurologist who is specialized
or experienced in the treatment of neuromuscular diseases, and
B. The patient (non-paraneoplastic diagnosis) has tried at least one of the
following therapies (a, b, or c), and
a. corticosteroid, or
b. azathioprine, or
c. another immunosuppressive agent (e.g., cyclosporine, myophenolate
mofetil)
C. The patient meets one of the following criteria (a b, c, or d).
a. The patient has had an inadequate response to one of these therapies
(corticosteroid, azathioprine, or another immunosuppressive agent), or
b. The patient could not tolerate one of these therapies (corticosteroid,
azathioprine or another immunosuppressive agent) 20 , or
c. The patient has contraindications to BOTH a corticosteroid and
azathioprine, or
d. The patient has paraneoplastic Lambert-Eaton myasthenic syndrome
(these patients do not have to try any of these other therapies).
In a placebo-controlled crossover trial, a single dose of IVIG produced significant
improvement in muscle strength and reduced serum calcium channel antibody
titers. Plasma exchange, steroids, and immunosuppressive agents have not been
studied in randomized controlled trials. 78 IVIG may be useful as adjunctive
therapy in difficult to treat patients. 20-21,27
26. Leukemia, acute lymphoblastic. Approve for 12 months in children with
hypogammaglobulinemia and either a history of severe invasive infection or with
recurrent sinopulmonary infections. According to a Canadian expert panel of
hematologists, IVIG is not recommended for routine use in children with hematologic
malignancies with or without hypogammaglobulinemia. 30 Two exceptions are
recommended by the expert panel. In children with hematologic malignancies with
acquired hypogammaglobulinemias and either a history of severe invasive infection
or recurrent sinopulmonary infections, IVIG may be an option. The second exception
is children registered in clinical trials that include IVIG in the protocol for treatment
of hematologic malignancies (and/or hematopoietic stem cell transplantation) even
without severe or recurrent infection.
This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this
guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is
based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence
to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider.
Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the
most recent CPT and HCPCS coding guidelines.
BMC HealthNet Plan – IVIG
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